Mass Disaster: Past and Present Current Trends: 5 th Annual Conference December 1, 2004

1. Mass Disaster: Past and PresentCurrent Trends: 5th Annual ConferenceDecember 1, 2004 Terrorism is the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives -Federal Bureau of Investigation Nizam Peerwani, M.D. Chief Medical Examiner Tarrant-Denton-Parker Counties, Texas Wednesday, December 1, 2004 peerwani@aol.com Anthrax Bacilli Gram Stain

2. Objectives • Mass Fatality & Legal Authority at Local Level • Role of Medical Examiner in Mass Fatality Event • Types of Events resulting in Mass Fatalities and Human Identification • “Bioterrorism” – a different model necessitating different approach Mass Casualty Disposition

3. Definition • Mass trauma is the term used to describe the injuries, death, disability, and emotional stress caused by a catastrophic event, such as a large-scale natural disaster or a terrorist attack • Mass Fatalities: Any situation in which there are more human bodies to be recovered and examined that can be handled by the resources of the existing facility. • Mass Fatalities in Tarrant-Denton-Parker: Is defined as any event where there are more than 10 casualties resulting from a single event Mass Casualty Disposition

4. Legal Authority • In Texas, the medical examiner is empowered by Statute 49.25 of the Code of Criminal Procedures which requires a duly appointed medical examiner to conduct “inquest” or inquiry into certain types of death including: • Deaths due to unnatural causes • Unattended deaths • Deaths that occur within 24 hours of admission Mass Casualty Disposition

5. Medical Examiners in Texas 2003 • Facts • Texas has no State Medical Examiner (ME) • Texas has a mixed ME and Coroner system • 13 MEs in Texas • MEs are located in 15 counties • Population served by ME counties is ~ 13 million (58% of state) • In Texas - Medical Examiners are: • Appointed Physicians licensed by the State Board of Medical Examiners • Trained and experienced in pathology, toxicology, histology, and other medicolegal sciences • Appointed by the County Commissioners Court Source: Bureau of Epidemiology and Bureau of Vital Statistics Mass Casualty Disposition For more information: david.zane@tdh.state.tx.us

6. Tarrant County Medical Examiner’s District - • Serves Tarrant, Parker and Denton Counties • Jurisdiction 3,000 SM • Population: 2.1 million • Cities served: 60 • Law Enforcement Agencies: 63 • Inquests: 8,000/year (40% of all deaths) Mass Casualty Disposition

7. Commissioners’ Court Table of Organization Mass Casualty Disposition

8. Four Forensic Pathologists Forensic Anthropologist Forensic Dentist Forensic Toxicologists Criminalists Latent Print Examiner Forensic Death Investigators Full-service Toxicology Lab Reference Crime Lab (52 full-time employees) Mass Casualty Disposition

9. 1st Major Terrorist Attack in the United States: April 19, 1995 Murray Federal Building: 5000 lbs of Ammonium Nitrate fertilizer in a Truck Mass Casualty Disposition

10. National Defense Policy Against Terrorism: Counterterrorism • The policy (June 21, 1995) evolved in the aftermath of Oklahoma Bombing on the 2nd anniversary of the Waco Disaster on April 19,1995 FBI Crisis Management Homeland Defense President Consequence Management FEMA Role? County Medical Examiners State/Local Agencies Mass Casualty Disposition

11. Role of Medical Examiner in Mass Fatality Event • Assessment of the Event • Death Scene Investigation • Body Recovery • Examinations • Identification of Human remains • Establishment of Cause and Manner of Death • Protect Personal Property and Evidence • Disposition of Remains to Loved Ones Mass Casualty Disposition

12. Mass Casualty Involvement by Tarrant County Staff • Delta Airline Crash at DFW Airport,1985 • Delta Airline Crash at DFW Airport, 1986 • Waco Disaster, 1993 • International: • Rwanda Genocide Investigation, 1996 • Bosnia & Kosovo, 1996-1997 • Guatemala, 1997 – 2002 • Afghanistan & Iraq Mass Graves, 2002- 2004 Mass Casualty Disposition

13. Types of Mass Fatality Events Natural Man-Made Fire: Hotel, School, Church Transportation: Aircraft, Bus etc Industrial: Chemical Terrorism: Domestic or Foreign Weather: Tornado, Flood Fire: Forest fire Earthquake Mass Casualty Disposition

14. Notification • Emergency Operations Center (EOC) • Police – Law Enforcement • News Media Mass Casualty Disposition

15. Koresh Compound on Thursday, April 22, 1993 Mass Casualty Disposition

16. “Bunker” Water Tower Kitchen/Dining Area Mass Casualty Disposition

17. Mass Casualty Disposition

18. Mass Casualty Disposition

19. Modes of Identification Visual: Body Intact Fingerprints Dental Body X-Rays DNA Mass Casualty Disposition

20. Fingerprint Comparison: AFIS Mass Casualty Disposition

21. Dental Mass Casualty Disposition

22. X-Ray Comparison Mass Casualty Disposition

23. DNA A Definitive …For Identification:Genomic (STR) or Mitochondrial Mass Casualty Disposition

24. 911 Taught Us That We Remain Unprepared Mass Casualty Disposition

25. Recovery Efforts Can Be Extremely Hazardous Destruction May Be Widespread Dense Smoke & Debris Several Days After The attack (September 15, 2001) Mass Casualty Disposition

26. Shifting Paradigm Mass Casualty Disposition

27. In a Bioterrorist Attack…. • In most cases, the cause of death will be clearly established by Hospital or Public Health Department • There will be involvement of FBI (as the lead law enforcement agency) • All deaths will be classified as “homicides” • Number of casualties will continue to arrive in reverse order • The major responsibility of the medical examiner will be to: • Take custody of the remains to establish the identity • To issue Death Certificate • Dispose remains to designated location or for burial Mass Casualty Disposition

28. Anthrax (Bacillus anthracis) Botulism (Clostridium botulinum toxin) Plague (Yersinia pestis) Smallpox (variola major) Tularemia (Francisella tularensis) Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo]) Highest Priority Agents: Can be easily disseminated or transmitted from person to person May cause high mortality, and have the potential for major public health impact Might cause public panic and social disruption Require special action for public health preparedness Category A/Diseases & Agents Mass Casualty Disposition

29. Multstuberculosis Nipah virus Tick-borne encephalitis]) Melioidosis (Burkholderia pseudomallei) Psittacosis (Chlamydia psittaci) Q fever (Coxiella burnetii) Ricin toxin from Ricinus communis (castor beans) Staphylococcal enterotoxin B Typhus fever (Rickettsia prowazekii) Viral encephalitis (alphaviruses [e.g., venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]) Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum) Second Highest Priority Agents include those that: are moderately easy to disseminate cause moderate morbidity and low mortality require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance Category B Diseases & Agents Mass Casualty Disposition

30. Hantaviruses Multidrug-resistant tuberculosis Nipah virus Tick-borne encephalitis viruses Tick-borne hemorrhagic fever viruses Yellow fever Third Highest Priority Agents include emerging pathogens that could be engineered for mass dissemination in the future because of: availability ease of production and dissemination potential for high morbidity and mortality and major health impact. Category C Diseases & Agents Mass Casualty Disposition

31. Inexperience: Most medical examiners have no field experience Anthrax: Vascular Thrombosis Anthrax Bacilli Smallpox: Pustules & Early Scarring Mass Casualty Disposition

32. Large-scale Act of Bioterrorism… • Federal and/or State Emergency • Local jurisdiction may be suspended and the medical examiner in a local area may play a supporting role only Mass Casualty Disposition